172870 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 360926 Page 1 of 1
ONE CIVIC SQUARE SHAVONNE HOLTON CHECK AMOUNT: $66.00
CARMEL, INDIANA 46032 8001 CANARY LANE, APT
ti4�o� Lod INDIANAPOLIS IN 46260 CHECK NUMBER: 172870
CHECK DATE: 5127/2009
DEPARTM ACCOUNT P NUMB INVOICE NUMBER AMOUNT DESC RIPTION
1046 4343004 66.00 TRAVEL PER DIEMS
PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1986)
MILEAGE CLAIM
TO-
(GOVERNMENTAL UNIT)
ON ACCOUNT OF APPROPRIATION NO. FOR
(OFFICE, BOARD, DEPARTMZNT OR INSTITUTION)
SPEEDOMETER
DATE FROM TO j READING AUTO 1
Za NATURE OF BUSINESS i MILES
POINT I POINT START FINISH ]'RAVELED PER MILE
r) C -e Y 1Tt r a
r
9- t r r te'
1.
m 4-CACeq() i- 10 _O..
r r r
IL
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f
AUTO LICENSE NO. TOTALS
SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.
Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount cla L1 .11 Jueafter io vi all just credits end that no partf theTame has been paid.
Dates �1 u°�
f>
MAY :t 3 2009
BY:
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to-be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
360926 Holton, Shavonne Terms
8001 Canary Ln Apt A Date Due
Indianapolis, IN 46260
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
5/8/09 Reimb. Mileage 1/22/09 4/28/09 66.00
Total 66.00
1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
1 20
Clerk- Treasurer
i
Voucher No. Warrant No.
360926 Holton, Shavonne Allowed 20
8001 Canary Ln Apt A
Indianapolis, IN 46260
In Sum of
66.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT#/TlTLE AMOUNT Board Members
Dept
1046 Reimb. 4343004 66.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
21 -May 2009
Signature
66.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund